A nomogram for predicting the in-hospital risk of recurrence among patients with minor non-cardiac stroke

BACKGROUND

Patients with minor stroke suffer a substantial risk of further recurrences, especially in the first two weeks. We aimed to develop and validate a prognostic nomogram to predict in-hospital stroke recurrence among patients with acute minor stroke.

METHODS

A total of 1326 patients with minor non-cardiac stroke (NIHSS) ≤5) from three centers were divided into development cohort (1016 patients from two centers) and validation cohort (310 patients from another center). Recurrent stroke was defined as a new ischemic stroke. A logistic regression model was employed to develop the nomogram to predict in-hospital stroke recurrence in patients with minor stroke using demographic, medical and imaging information. We then validated the nomogram externally. The predictive discrimination and calibration of the nomogram were assessed in the development and validation cohorts by area under the curve (AUC) and calibration plots.

RESULTS

During a median length of stay of 12 days, stroke recurrence occurred in 34 patients (3.3%). Predictors of in-hospital recurrence included prior history of transient ischemic attack, baseline NIHSS score, multiple infarctions, and carotid stenosis. The clinical and imaging-based nomogram B demonstrated adequate calibration and discrimination (AUC = 0.777), which was validated among 273 patients in a separate validation cohort (AUC = 0.753). Our clinical-imaging based nomogram was determined to be superior to the clinical-based nomogram and the RRE90 score in terms of discrimination.

CONCLUSION

A prognostic nomogram that integrates clinical and imaging information to predict the in-hospital risk of stroke recurrence among patients after acute minor stroke was constructed and validated externally. The nomogram demonstrated adequate calibration and discrimination in both the development and validation cohort.

Multiphase arterial spin labeling imaging to predict early recurrent ischemic lesion in acute ischemic stroke

In acute ischemic stroke (AIS), the hemodynamics around the lesion are important because they determine the recurrence or prognosis of the disease. This study evaluated the effects of perfusion deficits in multiphase arterial spin labeling (ASL) and related radiological parameters on the occurrence of early recurrent ischemic lesions (ERILs) in AIS. We assessed AIS patients who underwent multiphase ASL within 24 h of symptom onset and follow-up diffusion-weighted imaging within 7 days. ASL perfusion deficit, arterial transit artifact (ATA), and intra-arterial high-intensity signal (IAS) were manually rated as ASL parameters. A total of 134 patients were evaluated. In the multivariable analyses, ASL perfusion deficit [adjusted odds ratio (aOR) = 2.82, 95% confidence interval = 1.27–6.27] was positively associated with ERIL. Furthermore, when ATA was accompanied, the ASL perfusion deficit was not associated with ERIL occurrence. Meanwhile, IAS showed a synergistic effect with ASL perfusion deficit on the occurrence of ERIL. In conclusion, we demonstrated the association between perfusion deficits in multiphase ASL with ERIL in patients with AIS. This close association was attenuated by ATA and was enhanced by IAS. ASL parameters may help identify high-risk patients of ERIL occurrence during the acute period.

Predictive value of perfusion weighted imaging for early new lesions after stroke patients receive endovascular treatment

Background

Previous studies have focused on early new lesion-associated factors, but the differences in the perfusion status between the at-risk hypoperfusion areas with new lesions and the other hypoperfusion areas in stroke patients before thrombectomy is not clear. We investigated the value of perfusion-weighted imaging (PWI) in predicting early new lesions in patients after stroke.

Methods

Fifty-five acute stroke patients who underwent diffusion-weighted imaging (DWI) and PWI before and after thrombectomy within 24 h were eligible. The PWI parameters of the core infarct areas (high signal tissue on the DWI), the at-risk hypoperfusion areas (hypoperfusion area with new lesions at follow-up PWI) and the other hypoperfusion areas of patients with new lesions were collected. Statistical analysis was performed to predict new lesions after stroke. The differences in the PWI parameters of the core infarct areas, the at-risk hypoperfusion areas and the other hypoperfusion areas were compared. Receiver operating characteristic (ROC) curve analysis was used to assess the predictive value of the PWI parameters (P<0.05) for the occurrence of new lesions in patients with acute stroke after thrombectomy.

Results

Fifty-five stroke patients were analyzed, including forty patients (72.73%) with new lesions and fifteen patients (27.27%) without new lesions. Acute stroke patients with new lesions had a longer mean transit time (MTT) and time to peak (TTP) in the at-risk hypoperfusion areas (11.95±3.29; 38.30±11.39) than in the other hypoperfusion areas (8.68±2.08; 29.76±6.86), both of which were significantly different (P<0.0001; P<0.0001, respectively). The ROC analysis showed that the sensitivity and specificity of MTT for predicting the occurrence of new lesions after stroke were 70.00% and 87.50%, respectively; the sensitivity and specificity of TTP were 70.00% and 80.00%, respectively.

Conclusions

MTT and TTP may be useful in predicting early new lesions in acute stroke patients after thrombectomy.

High triglyceride-glucose index is associated with early recurrent ischemic lesion in acute ischemic stroke

The triglyceride-glucose (TyG) index has been associated with various metabolic, cardiovascular, and cerebrovascular diseases. We evaluated the association between the TyG index and early recurrent ischemic lesions (ERILs) in patients with acute ischemic stroke (AIS). We included consecutive patients diagnosed with AIS between 2010 and 2016. ERILs were defined as new diffusion-weighted imaging lesions outside the initial symptomatic lesion area. The TyG index was calculated using the following formula: log scale of fasting triglyceride × fasting glucose/2. A total of 176 patients with AIS were evaluated. In the multivariable analysis, the TyG index remained significant (adjusted odds ratio [aOR] 2.63, 95% confidence interval [CI] 1.34–5.15). This close correlation between the TyG index and ERIL was pronounced in ERIL-same group (aOR 2.84, 95% CI 1.40–5.78), but not in ERIL-different group. When comparing the relationship between the TyG index and ERIL by stroke mechanisms, only the intracranial- and extracranial-large artery atherosclerosis groups showed significantly higher TyG index values in patients with ERIL than those without. In conclusion, a higher TyG index was associated with ERIL, especially ERIL-same, in patients with AIS. The TyG index appears to be involved in ERIL occurrence by a mechanism related to atherosclerosis.

Short-Term and Long-Term Safety and Efficacy of Treatment of Acute Ischemic Stroke with Low-Molecular-Weight Heparin: Meta-Analysis of 19 Randomized Controlled Trials

OBJECTIVE

Currently, it remains controversial about guidelines for the application of low-molecular-weight heparin (LMWH) in patients with acute ischemic stroke (AIS). Therefore this meta-analysis was carried out, aiming to systematically investigate the short-term and long-term safety and efficacy of LMWH in AIS patients.

METHODS

Three electronic databases-PubMed, Embase database, and Cochrane library-were comprehensively retrieved by 2 investigators independently. Finally, a total of 19 randomized controlled trials were enrolled for analysis. The safety endpoints in this study included all-cause mortality and the risk of bleeding (major, minor, or cerebral hemorrhage). The efficacy endpoints were the prevention of deep vein thrombosis (DVT) and recurrent stroke.

RESULTS

The application of LMWH led to a decreased risk of DVT, and there was no significant association in all-cause mortality or recurrent stroke. According to age-stratified analyses, the risk of all-cause mortality increased by 39% (risk ratio 1.39, 1.03-1.88; I² 0%) in AIS patients aged older than 70 years who used LMWH for 14 days, and there was no significant effect on preventing DVT (risk ratio 0.69, 0.14-3.52; I² 26.4%) in patients aged younger than 70 years old within 3 months. Moreover, enoxaparin and danaparoid were more effective at preventing DVT, regardless of age.

CONCLUSIONS

To sum up, on the basis of limited studies available currently, the early use of LMWH in AIS patients aged older than 70 years should be cautious because it may increase the risk of all-cause mortality. For patients younger than 70 years old, the early use of LMWH significantly reduces the short-term risk of DVT, but there is no significant relationship in the long term. In terms of DVT prevention, enoxaparin and danaparoid are probably more effective. Nonetheless, more future randomized controlled trials are warranted to verify and support this conclusion.

Aspirin plus clopidogrel versus aspirin mono-therapy for ischemic stroke: a meta-analysis

Objectives. Stroke is a common condition after a transient ischemic attack (TIA) or minor ischemic stroke (IS). Adding clopidogrel to aspirin may yield more beneficial outcomes than aspirin mono-therapy; meanwhile, the risk of bleeding in the acute phase remains poorly understood. Therefore, there is increasing emphasis on the risks and benefits of clopidogrel with aspirin compared with aspirin mono-therapy in an effort to treat TIA/IS. Design. We searched several electronic databases, including PubMed, Cochrane, and Embase, to identify eligible randomized controlled trials (RCTs) based on the index words comparing dual-antiplatelet therapy to aspirin mono-therapy for secondary stroke prevention updated to December, 2018. Results. A total of 11 RCTs met our inclusion criteria. The pooled analysis showed that clopidogrel plus aspirin was associated with a trend toward a reduction in recurrent IS (RR = 0.72, 95%CI = 0.65-0.81, p < .001), but not the recurrent stroke rate (RR = 0.81, 95% CI = 0.63-1.03, p = .09) than aspirin mono-therapy. There were differences in bleeding episodes (RR = 1.81, 95%CI = 1.65-1.99, p < .001), moderate-severe major bleeding (RR = 1.64, 95% CI = 1.24-2.16, p = .0005), or mild bleeding (RR = 2.25, 95%CI = 1.54-3.31, p < .001) between the study groups. Meanwhile, no benefit of reducing the risk of intracranial hemorrhage with dual-antiplatelet therapy was found in TIA/IS patients (RR = 1.44, 95% CI = 0.95-2.19, p = .09). Conclusions. The addition of clopidogrel to aspirin for patients with TIA or IS appeared to significantly reduce the risk of IS recurrence with a possible increase in the risk of bleeding compared with aspirin alone.

New Silent Cerebral Infarction in Patients with Acute Non-Cerebral Amyloid Angiopathy Intracerebral Hemorrhage as a Predictor of Recurrent Cerebrovascular Events

BACKGROUND The aim of this study was to investigate the incidence and related risk factors of new silent cerebral infarction in patients with acute non-cerebral amyloid angiopathy (non-CAA) intracerebral hemorrhage (ICH) and to explore clinical cerebrovascular event recurrence within 1 year. MATERIAL AND METHODS This prospective study observed 152 patients with non-CAA ICH diagnosed by computed tomography within 3 days after onset. All patients underwent magnetic resonance imaging on day 14 to identify silent cerebral infarction, and their subsequent clinical cerebrovascular events were followed up regularly within 1 year. RESULTS Of the 152 patients, 46 (30.26%) had silent cerebral infarctions. Multiple logistic regression analysis revealed that the white blood cell (WBC) count, cerebral microbleeds (CMBs), and leukoaraiosis were silent cerebral infarction risk factors. At 1-year follow-up, 34 (22.37%) had clinical cerebrovascular events, with 8 (23.53%) having vascular-related deaths. Multiple logistic regression analysis showed that silent cerebral infarction was the only independent predictor of future clinical cerebrovascular events. CONCLUSIONS Silent cerebral infarction is common during acute non-CAA ICH and is independently related to WBC counts, CMBs, and leukoaraiosis. The risk of clinical cerebrovascular events in non-CAA ICH patients with silent cerebral infarction increases in the following year; thus, silent cerebral infarction may be a useful predictor of recurrent cerebrovascular events.

Early Recurrent Ischemic Lesions in Patients With Cryptogenic Stroke and Patent Foramen Ovale: An Observational Study

Background: Randomized controlled trials indicate that patent foramen ovale (PFO) closure reduces risk of stroke recurrence in patients with cryptogenic stroke and PFO. However, the optimal time point for PFO closure is unknown and depends on the risk of stroke recurrence.

Objective: We aimed to investigate risk of early new ischemic lesions on cerebral magnetic resonance imaging (MRI) in cryptogenic stroke patients with and without PFO.

Methods: Cryptogenic stroke patients underwent serial MRI examinations within 1 week after symptom onset to detect early new ischemic lesions. Diffusion-weighted imaging (DWI) lesions were delineated, co-registered, and analyzed visually for new hyperintensities by raters blinded to clinical details. A PFO was classified as stroke-related in patients with PFO and a Risk of Paradoxical Embolism (RoPE) score >5 points.

Results: Out of 80 cryptogenic stroke patients, risk of early recurrent DWI lesions was not significantly different in cryptogenic stroke patients with and without PFO. Similar results were observed in patients ≤60 years of age. Patients with a stroke-related PFO even had a significantly lower risk of early recurrent ischemic lesions compared to all other patients with cryptogenic stroke (unadjusted odds ratio 0.23 [95% confidence interval 0.06–0.87], P = 0.030).

Conclusion: Our data argue against a high risk of early stroke recurrence in patients with cryptogenic stroke and PFO.

Introduction of direct oral anticoagulant within 7 days of stroke onset: a nomogram to predict the probability of 3-month modified Rankin Scale score > 2

In clinical practice, direct oral anticoagulants (DOACs) are often started earlier (≤ 7 days) than in randomized clinical trials after stroke. We aimed to develop a nomogram model incorporating time of DOAC introduction ≤ 7 days of stroke onset in combination with different degrees of stroke radiological/neurological severity at the time of treatment to predict the probability of unfavorable outcome. We conducted a multicenter prospective study including 344 patients who started DOAC 1-7 days after atrial fibrillation-related stroke onset. Computed tomography scan 24-36 h after stroke onset was performed in all patients before starting DOAC. Unfavorable outcome was defined as modified Rankin Scale (mRS) score > 2 at 3 months. Based on multivariate logistic model, the nomogram was generated. We assessed the discriminative performance by using the area under the receiver operating characteristic curve (AUC-ROC) and calibration of risk prediction model by using the Hosmer-Lemeshow test. Onset-to-treatment time for DOAC (OR: 1.21, p = 0.030), NIH Stroke Scale (NIHSS) score at the time of treatment (OR: 1.00 for NIHSS = 0-5; OR: 2.67, p = 0.016 for NIHSS = 6-9; OR: 26.70, p < 0.001 for NIHSS = 10-14; OR: 57.48, p < 0.001 for NIHSS ≥ 15), size infarct (OR: 1.00 for small infarct; OR: 2.26, p = 0.023 for medium infarct; OR: 3.40, p = 0.005 for large infarct), and age ≥ 80 years (OR: 1.96, p = 0.028) remained independent predictors of unfavorable outcome to compose the nomogram. The AUC-ROC of nomogram was 0.858. Calibration was good (p = 2.889 for the Hosmer-Lemeshow test). The combination of onset-to-treatment time of DOAC with stroke radiological/neurological severity at the time of treatment and old age may predict the probability of unfavorable outcome.

Significance of Multiple Acute Ischemic Lesions on Initial Diffusion-weighted Imaging in Stroke Patients and Relation of Toast Classification

Background

It is important to know whether or not the stroke risk factors and etiologies of patients with multiple acute infarcts are different to those of patients with a single acute infarct.

Aim

The frequency of multiple acute infarct was investigated in ischemic stroke patients and a comparison was made of the characteristics of stroke patients with and without multiple acute infarct.

Patients and Methods

We reviewed the clinical records of 988 ischemic stroke patients who were admitted within 1 week of the onset of stroke and diffusion-weighted imaging (DWI) was performed on first presentation. The clinical characteristics, laboratory, and imaging results were noted from the patient records. According to the DWI findings, the patients were separated into three groups as those with a single acute infarct in a single vascular territory (SI group), those with multiple acute infarcts in a single vascular territory (SMI group) and those with multiple acute infarcts in multiple vascular (MMI group) territories. The frequency of multiple acute infarcts was investigated, and a comparison was made of the characteristics of stroke patients with and without multiple acute infarcts.

Results

The SMI group included 119 (12%) patients and the MMI group 126 (12.8%). The most common mechanisms of multiple acute infarcts are large artery atherosclerosis and cardiac origin emboli. Moreover, the risk factors most determined were hypertension, diabetes mellitus, and hyperlipidemia in the MMI group.

Conclusion

No difference was determined between the groups in respect of stroke etiology and risk factors.

Early New Ischemic Lesions Located Outside the Initially Affected Vascular Territory Appear More Often in Stroke Patients with Elevated Glycated Hemoglobin (HbA1c)

Background

Early new ischemic lesions are common in patients with an acute ischemic stroke. These new ischemic lesions may represent the natural course of the initial stroke or de novo events.

Objective

We hypothesized that early new ischemic lesions located outside the initially affected vascular territory would point at de novo events. Therefore, we differentiated new ischemic lesions located outside the initially affected vascular territory from those occurring only inside the initially affected vascular territory to identify risk factors that are associated with de novo events.

Methods

Stroke patients underwent three magnetic resonance imaging examinations (at 3-T): on admission, on the next day and 4–7 days after symptom onset (clinicaltrials.gov: NCT00715533). Diffusion-weighted imaging (DWI) lesions were delineated, coregistered, and then analyzed for new hyperintensities on follow-up examinations by raters blinded to clinical details. Patients were classified as having “new distant lesions” if new DWI lesions appeared outside or both outside and inside the initially affected vascular territory or “new local lesions” if they were only inside.

Results

115 patients with early new DWI lesions constitute the study population. Sixteen patients (14%) had new distant lesions and 99 patients (86%) had new local lesions. In comparison between patients with new distant and new local lesions, patients with new distant lesions had significantly more often elevated glycated hemoglobin (HbA1c ≥ 6.5%; p = 0.022).

Conclusion

Our data indicate that patients with elevated HbA1c have an increased risk for new, de novo ischemic lesions in the acute phase after an ischemic stroke.

Importance and Difficulties of Pursuing rTMS Research in Acute Stroke

Although much research has been done on repetitive transcranial magnetic stimulation (rTMS) in chronic stroke, only sparse research has been done in acute stroke despite the particularly rich potential for neuroplasticity in this stage. We attempted a preliminary clinical trial in one active, high-quality inpatient rehabilitation facility (IRF) in the -United States. But after enrolling only 4 patients in the grant period, the study was stopped because of low enrollment. The purpose of this paper is to offer a perspective describing the important physiologic rationale for including rTMS in the early phase of stroke, the reasons for our poor patient enrollment in our attempted study, and recommendations to help future studies succeed. We conclude that, if scientists and clinicians hope to enhance stroke outcomes, more attention must be directed to leveraging conventional rehabilitation with neuromodulation in the acute phase of stroke when the capacity for neuroplasticity is optimal. Difficulties with patient enrollment must be addressed by reassessing traditional inclusion and exclusion criteria. Factors that shorten patients' length of stay in the IRF must also be reassessed at all policy-making levels to make ethical decisions that promote higher functional outcomes while retaining cost consciousness.

Previous Statin Use and High-Resolution Magnetic Resonance Imaging Characteristics of Intracranial Atherosclerotic Plaque: The Intensive Statin Treatment in Acute Ischemic Stroke Patients With Intracranial Atherosclerosis Study

BACKGROUND AND PURPOSE

Although statin use has been linked to the stabilization of systemic atherosclerosis, its effect on symptomatic intracranial atherosclerotic plaques has yet to be explored. We hypothesized that premorbid statin use is associated with plaque instability in intracranial arteries and may lead to differential patterns (size and distribution) of ischemic lesions in patients with acute intracranial atherosclerotic stroke.

METHODS

One hundred and thirty-six patients with acute infarcts caused by intracranial atherosclerotic stroke underwent high-resolution magnetic resonance imaging. Patients were categorized into 3 groups based on their premorbid statin use: nonuser, low-dose user, and high-dose user, according to the 2013 American College of Cardiology/American Heart Association guidelines on blood cholesterol. Symptomatic lesions in intracranial arteries were analyzed using high-resolution magnetic resonance imaging for vascular morphology (degree of stenosis, remodeling index, and wall index) and plaque activation (pattern and volume of enhancement). The cortical distribution and volume of ischemic brain lesions were measured using diffusion-weighted imaging.

RESULTS

Among the enrolled patients, 38 (27.94%) were taking statins before the index stroke (22 low-dose statins and 16 high-dose statins). The degree of stenosis, remodeling index, and wall index did not differ between the 3 groups. However, the volume of plaque enhancement was significantly lower in statin users (nonuser, 33.26±40.72; low-dose user, 13.15±17.53; high-dose user, 3.13±5.26; P=0.002). Premorbid statin use was associated with a higher prevalence of nonembolic stroke and a decrease in large cortical infarcts (P=0.012).

CONCLUSIONS

Premorbid statin usage is independently associated with reduced plaque enhancement and a decrease in large cortical lesions in patients with intracranial atherosclerotic stroke.

Silent new ischemic lesions after index stroke and the risk of future clinical recurrent stroke

OBJECTIVE

To test whether a silent new ischemic lesion (SNIL) on MRI after stroke predicted future recurrent ischemic stroke or vascular events.

METHODS

In this prospective study, we analyzed data from patients presenting with acute ischemic stroke who underwent MRI <24 hours and 5 and 30 days after symptom onset. The presence of a SNIL at 5 (5D-SNIL) and 30 (30D-SNIL) days was determined on diffusion-weighted and fluid-attenuated inversion recovery images. Patients were contacted every 3-6 months to identify recurrent clinical events. The log-rank test and Cox proportional hazard model were used to estimate the hazard ratio of recurrent ischemic stroke and composites of recurrent ischemic stroke, transient ischemic attack, acute coronary syndrome, and vascular death.

RESULTS

The 5D- and 30D-SNILs were found in 24.4% (66/270) and 7.4% (19/256) of patients. During the 5-year follow-up, clinical events were observed in 42 patients (15.6%). The 5D- and 30D-SNIL independently predicted recurrent ischemic stroke (hazard ratio [95% confidence interval] 2.9 [1.3-6.4] and 9.6 [4.1-22.1], respectively) and composite vascular events (2.4 [1.3-4.5] and 6.1 [3.1-12.4], respectively).

CONCLUSIONS

Patients with a SNIL within the first few weeks after index stroke have an increased risk of recurrent ischemic stroke or vascular events. The presence of a SNIL on MRI could serve as a surrogate endpoint for clinical recurrence in secondary prevention clinical trials.

Distribution of ischemic infarction and stenosis of intra- and extracranial arteries in young Chinese patients with ischemic stroke

Background

The distribution of cerebral ischemic infarction and stenosis in ischemic stroke may vary with age-group, race and gender. This study was conducted to understand the risk factors and characteristics of cerebral infarction and stenosis of vessels in young Chinese patients with ischemic stroke.

Methods

This was a retrospective study, from January 2007 to July 2012, of 123 patients ≤50 years diagnosed with acute ischemic stroke. Patient characteristics were compared according to sex (98 males and 25 females) and age group (51 patients were ≤45 years and 72 patients were 46–50 years). Characteristics of acute ischemic infarction were studied by diffusion weighted imaging. Stenosis of intra- and extracranial arteries was diagnosed by duplex sonography, head magnetic resonance angiography (MRA) or cervical MRA.

Results

Common risk factors were hypertension (72.4 %), dyslipidemia (55.3 %), smoking (54.4 %) and diabetes (33.3 %). Lacunar Infarction was most common in our patients (41.5 %). Partial anterior circulation infarction was predominant in females (52.0 vs 32.7 %; P = 0.073) and posterior circulation infarction in males (19.8 vs 4 %; P = 0.073). Multiple brain infarctions were found in 38 patients (30.9 %). Small artery atherosclerosis was found in 54 patients (43.9 %), with higher prevalence in patients of the 46–50 years age-group. Intracranial stenosis was more common than extracranial stenosis, and middle cerebral artery stenosis was most prevalent (27.3 %). Stenosis in the anterior circulation was more frequent than in the posterior circulation (P < 0.001).

Conclusions

In these young patients, hypertension, smoking, dyslipidemia and diabetes were common risk factors. Intracranial stenosis was most common. The middle cerebral artery was highly vulnerable.

Silent New Brain Lesions: Innocent Bystander or Guilty Party?

With the advances in magnetic resonance imaging, previously unrecognized small brain lesions, which are mostly asymptomatic, have been increasingly detected. Diffusion-weighted imaging can identify small ischemic strokes, while gradient echo T2* imaging and susceptibility-weighted imaging can reveal tiny hemorrhagic strokes (microbleeds). In this article, we review silent brain lesions appearing soon after acute stroke events, including silent new ischemic lesions and microbleeds appearing 1) after acute ischemic stroke and 2) after acute intracerebral hemorrhage. Moreover, we briefly discuss the clinical implications of these silent new brain lesions.

In-hospital stroke recurrence and stroke after transient ischemic attack: frequency and risk factors

BACKGROUND AND PURPOSE

We aimed to assess the risk of recurrent ischemic events during hospitalization for stroke or transient ischemic attack (TIA) with optimal current management and to identify associated risk factors.

METHODS

We performed a retrospective analysis of all patients treated for acute ischemic stroke or TIA in 3 stroke units between 2010 and 2013. Recurrent stroke was defined as new persisting (≥24 hours) neurological deficit occurring >24 hours after the index event and not attributable to other causes of neurological deterioration. Cox proportional hazard regression identified risk factors associated with recurrent stroke.

RESULTS

The study included 5106 patients. During a median length of stay of 5 days (interquartile range, 4-8), stroke recurrence (or stroke after TIA) occurred in 40 patients (0.8%) and was independently associated with history of TIA, symptomatic carotid stenosis (≥70%), or other determined etiology. Patients with recurrent stroke and other determined etiology had cervical arterial dissection (n=2), primary angiitis of the central nervous system (n=1), giant cell arteritis (n=1), and lung cancer with nonbacterial thrombotic endocarditis (n=1). In patients with initial TIA or minor stroke (National Institutes of Health Stroke Scale ≤5) recurrence was associated additionally with pneumonia after the inciting ischemic event but before stroke recurrence. Patients with initial stroke and aphasia had a lower stroke recurrence rate and there were no recurrences in patients with lacunar stroke. Recurrence was associated with significantly higher in-hospital mortality (17.5% versus 3.1%; P<0.001).

CONCLUSIONS

In-hospital stroke recurrence was low with optimal current management. Patients with a history of TIA, severe symptomatic carotid stenosis, or uncommon causes of stroke were at higher risk. Pneumonia was associated with a higher risk of stroke recurrence in patients with initial TIA or minor stroke but not in the overall population studied. Aphasia may bias the detection rate by concealing new neurological symptoms.

Low-molecular-weight heparin or dual antiplatelet therapy is more effective than aspirin alone in preventing early neurological deterioration and improving the 6-month outcome in ischemic stroke patients

BACKGROUND AND PURPOSE

Dual antiplatelet therapy (DAT) with clopidogrel and aspirin has been shown to confer greater protection against early neurological deterioration (END) and early recurrent ischemic stroke (ERIS) than aspirin alone in patients who have experienced an acute ischemic stroke. However, few studies have compared the effects of anticoagulation therapy with low-molecular-weight heparin (LMWH), DAT, and aspirin.

METHODS

Patients with acute ischemic stroke (n=1,467) were randomized to therapy groups receiving aspirin (200 mg daily for 14 days, followed by 100 mg daily for 6 months), DAT (200 mg of aspirin and 75 mg of clopidogrel daily for 14 days, then 100 mg of aspirin daily for 6 months), or LMWH (4,000 antifactor Xa IU of enoxaparin in 0.4 mL subcutaneously twice daily for 14 days, followed by 100 mg of aspirin daily for 6 months). The effects of these treatment strategies on the incidence of END, ERIS, and deep-vein thrombosis (DVT) were observed for 10-14 days after treatment, and their impacts on a good outcome were evaluated at 6 months.

RESULTS

The DAT and LMWH were associated with a more significant reduction of END and ERIS within 14 days compared with aspirin-alone therapy. In addition, LMWH was associated with a significantly lower incidence of DVT within 14 days. At 6 months, DAT or LMWH improved the outcome among patients aged >70 years and those with symptomatic stenosis in the posterior circulation or basilar artery compared with aspirin.

CONCLUSIONS

LMWH or DAT may be more effective than aspirin alone for reducing the incidence of END and ERIS within 14 days, and is associated with improved outcomes in elderly patients and those with stenosis in the posterior circulation or basilar artery at 6 months poststroke.

CYP2C19 genotype and early ischemic lesion recurrence in stroke patients treated with clopidogrel

BACKGROUND

Early recurrent ischemic lesions detected on diffusion-weighted imaging (DWI) have been proposed as a surrogate marker for clinical recurrence. We hypothesized that cytochrome P450 2C19 (CYP2C19) genotype influences the incidence of early recurrence on DWI in acute stroke patients treated with clopidogrel.

METHODS

We enrolled 76 Korean patients with acute ischemic stroke due to large artery atherosclerosis who were treated with clopidogrel. Early ischemic lesion recurrence was defined as new lesions separate from the index lesion. We compared the rates of early ischemic lesion recurrence on DWI based on the CYP2C19 genotypes.

RESULTS

Early recurrence on DWI was observed in 36 patients (47.4%). A total of 76 patients were classified into 3 phenotypic groups: extensive metabolizers (EMs; n = 27, 35.5%), intermediate metabolizers (IMs; n = 36, 47.4%), and poor metabolizers (PMs; n = 13, 17.1%). Early recurrence on DWI was more common in PMs (84.6%), followed by IMs (50.0%), and EMs (25.9%; P < .001). PMs had a significantly higher recurrence rate than EMs (P < .001). In multivariate analysis, CYP2C19 genotypes were independently associated with early DWI recurrence (for PMs: odds ratio, 19.3; 95% confidence interval, 3.15-117.56).

CONCLUSIONS

CYP2C19 genotypes are significantly associated with early lesion recurrence in Korean acute stroke patients treated with clopidogrel.

Clopidogrel Plus Aspirin Prevents Early Neurologic Deterioration and Improves 6-Month Outcome in Patients With Acute Large Artery Atherosclerosis Stroke

Aims:

To evaluate the effects of treatments with clopidogrel plus aspirin (dual therapy) on early neurological deterioration (END) and outcomes at 6 months in patients with acute large artery atherosclerosis (LAA) stroke.

Methods:

A total of 574 patients with LAA stroke were randomly assigned to receive either dual therapy or aspirin alone (monotherapy). The primary outcome was END. Secondary outcomes included recurrent ischemic stroke (RIS) and outcomes at 6 months.

Results:

The prevalence of END and RIS was lower in patients on dual therapy than in those on monotherapy during the 30 days. At 6 months, dual therapy improved outcomes among older patients and those with symptomatic stenosis in the posterior circulation and basilar artery.

Conclusion:

Clopidogrel plus aspirin is superior to aspirin alone for reducing END and RIS within 30 days and improves outcomes in certain subgroups at 6 months.

Can early effective anticoagulation prevent new lesions on magnetic resonance imaging in acute cardioembolic stroke?

BACKGROUND

The timing of warfarin administration for acute ischemic stroke (AIS) patients with atrial fibrillation (Af) has not been established. We hypothesized that achieving targeted prothrombin time and international normalized ratio (PT-INR) at 2 weeks could prevent AIS patients with Af from developing a new lesion on diffusion-weighted magnetic resonance imaging (DW-MRI).

METHODS

Of consecutively enrolled AIS patients with Af between 2008 and 2011, we selected the patients who were given warfarin within 2 weeks of admission and had DW-MRI and blood test for PT-INR both on admission and at 2 weeks. Warfarin was started as early as possible and heparin was administered until the targeted PT-INR (2.0-3.0 for patients aged <70 years or 1.6-2.6 for those aged ≥70 years) was achieved.

RESULTS

One hundred and twenty-three patients were selected, consisting of 88 patients without a new lesion and 35 patients with a new lesion. Patients with a new lesion had a significantly higher median score on National Institutes of Health Stroke Scale (11.0 vs. 5.5, P = .0053), a lower rate of achieving targeted PT-INR at 2 weeks (25.7% vs. 48.9%, P = .0190), and a lower median dosage of warfarin at 2 weeks (2.0 mg vs. 2.5 mg, P = .0209) than patients without a new lesion. Multivariate logistic regression analysis showed that failure to achieve targeted PT-INR (P = .0298) was significantly associated with the occurrence of a new lesion.

CONCLUSIONS

Our findings suggest that achieving targeted PT-INR at 2 weeks by using warfarin prevents new lesions in AIS patients with Af.

A comparative study of dual versus monoantiplatelet therapy in patients with acute large-artery atherosclerosis stroke

BACKGROUND

Antiplatelet drugs are recommended for patients with acute noncardioembolic stroke. However, few randomized clinical trials have investigated the safety and efficacy of dual antiplatelet therapy for these patients. The aim of this study was to evaluate the effects of treatment with clopidogrel and aspirin (combination therapy) and aspirin alone (monotherapy) on neurologic deterioration, platelet activation, and other short-term outcomes in patients with acute large-artery atherosclerosis stroke.

MATERIALS AND METHODS

Altogether 574 patients with acute (≤2 days) large-artery atherosclerosis stroke were randomly assigned to receive either combined clopidogrel and aspirin or aspirin alone. Platelet aggregation and platelet-leukocyte aggregation studies were performed at days 1 and 30. Primary outcomes including recurrent ischemic stroke, neurologic deterioration, periphery vascular events, and myocardial infarction were monitored. Safety endpoints were hemorrhagic episodes and death.

RESULTS

The prevalence of neurologic deterioration and recurrent ischemic stroke were lower in patients in the combination therapy group than in those of the monotherapy group (3.52% versus 9.78% and 1.76% versus 6.29%, respectively). At day 30 of treatment, the platelet aggregations and platelet-leukocyte aggregates were lower in patients who were treated with clopidogrel and aspirin than in patients given aspirin alone (P < .001).

CONCLUSIONS

For patients with acute large-artery atherosclerosis stroke, treatment with clopidogrel and aspirin for 1 month provided significantly greater inhibition of platelet activity than aspirin alone. Thus, dual therapy can be safer and more effective in reducing ischemic stroke recurrence and neurologic deterioration.

Complete Early Reversal of Diffusion-Weighted Imaging Hyperintensities After Ischemic Stroke Is Mainly Limited to Small Embolic Lesions

Background and Purpose—

Case reports have demonstrated complete early reversal of hyperintensities on diffusion-weighted imaging (DWI) after clinically diagnosed stroke. We aimed to investigate systematically the rate and characteristics of reversible diffusion hyperintensities (RDHs) in the first week after stroke.

Methods—

Patients with clinical diagnosis of an acute cerebrovascular event and evidence of ischemia on DWI were included. MRI scans were performed on admission, on the following day, and 4 to 7 days after onset of symptoms with DWI and fluid-attenuated inversion recovery. Baseline and follow-up DWIs were coregistered and examined for individual RDHs. Characteristics of patients and of hyperintensities associated with early reversal were identified.

Results—

We included 153 patients with a median National Institutes of Health Stroke Scale score of 4 (interquartile range, 2–8). In 3 patients (2%), MR images normalized completely. Thirty-seven patients (24%) displayed individual RDHs. Of 611 initial DWI hyperintensities, 97 (16%) reversed. Thirteen percent of the RDHs had corresponding abnormalities on fluid-attenuated inversion recovery images at the third measurement. Median size of the RDHs was 0.029 mL (interquartile range, 0.013–0.055). RDHs were associated with a multiple infarct pattern (odds ratio, 22.1; 95% confidence interval, 4.5–109.7) and symptomatic carotid stenosis (odds ratio, 5.5; 95% confidence interval, 1.4–21.5). Fifty-nine percent of the patients with RDHs had new additional lesions on follow-up DWI. RDHs were not associated with functional improvement on the National Institutes of Health Stroke Scale score.

Conclusions—

In this population of mainly minor to moderate stroke patients, complete normalization of MR images was rare. Complete reversal of individual DWI hyperintensities was limited to very small lesions and mostly occurred in embolic stroke patients.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00715533.

Incidence of New Diffusion-Weighted Imaging Lesions Outside the Area of Initial Hypoperfusion Within 1 Week After Acute Ischemic Stroke

Background and Purpose—

New diffusion-weighted imaging (DWI) lesions are common in patients with acute ischemic stroke. The pathophysiology of these new lesions is unclear. We differentiated new DWI lesions outside the area of initial hypoperfusion from those confined to the area of initial hypoperfusion.

Methods—

Patients with acute stroke underwent 3 MRI examinations: on admission, on the next day, and 4 to 7 days after symptom onset. Patients were included if a perfusion deficit was present on the initial scan. Lesions on DWI images were delineated manually. Coregistered DWI images were analyzed visually for new hyperintensities. In reference to the perfusion maps (mean transit time), patients were classified as having “outside lesions” if new DWI lesions were outside or both outside and inside the area of the initial perfusion deficit or “inside lesions” if new DWI lesions were completely inside.

Results—

We enrolled 164 patients. Thirty-eight patients (23%) had outside lesions and 34 patients (21%) had inside lesions. In multivariable regression analysis, new outside lesions were significantly associated with symptomatic carotid stenosis, multiple index lesions pattern, and high low-density lipoprotein levels. New inside lesions were significantly associated with (spontaneous or thrombolytic) vessel recanalization, multiple index lesions pattern, and low low-density lipoprotein levels.

Conclusion—

Outside and inside lesions represent different pathophysiological entities. More specifically patients with outside lesions may have an increased risk for subsequent cerebrovascular events.